Surgical Strategies for Hepatoblastoma Involving Four Liver Sectors, Look Back to Look Forward: Lessons From a Single‐Center Experience

Liver transplantation (LT) has been recommended for hepatoblastoma (HB) involving all four liver sectors at diagnosis (PRETEXT IV). However, recent studies question the universal indication for primary LT in PRETEXT IV HB. We reviewed 32 PRETEXT IV HB patients treated at our center from February 2007 to July 2024. A multidisciplinary team reassessed surgical resectability to evaluate treatment strategies for PRETEXT IV HB. Of 32 patients, 28 (87.5%) underwent LT, while 4 (12.5%) underwent liver resection (LR). Median follow-up was 4.6 years (IQR 2.3-8.5). The tumor, which was deemed radiologically resectable before surgery, was found pathologically unresectable in two LT patients: viable tumor microembolism at sites where the tumor was present at diagnosis in one patient and severe tumor ossification close to the major vascular system in one patient. Four patients with tumor thrombus, unresectable radiologically, were pathologically resectable using LR with extracorporeal circulation. Among the four patients undergoing LR, two patients eventually received LT. One had a recurrence at the initial tumor site, and the other developed cirrhosis post-LR. Surgical complications occurred in three LT patients and one LR patient. No complications related to long-term immunosuppression have been observed in LT patients. However, one LT patient developed portal hypertension due to chronic rejection and is awaiting a deceased donor LT. One LT patient died due to recurrence. Despite uncertainties about long-term LT outcomes, LT remains the preferred strategy for safely achieving complete resection in PRETEXT IV HB patients.